HomeMy WebLinkAboutBLD2006-00552I
• MLA06-00535
Review Type: I
MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00552 Received Date: 9/28/2006
SITE ADDRESS: 111 MADRONA VISTA PL
PORT LUDLOW, 98365
APPLICANT: RUTH A WILLIAMSON PHONE: 360-779-6882
3009 NE BABOCK ST
POULSBO WA 89370
SUBDIVISION: MADRONA VISTA 1ST AD Block: Lot: 5
PARCEL NUMBER: 970300004 Section: 34 Township: 28 N Range: 01 E
CONTRACTOR/ GOLDEN HOMES OF POULSBO PHONE: 360-697-3456
DEALER: 19647 VIKING AVE NW
POULSBO WA 98370
97 4606
FQ �
Contractor's License GOLDEHP950KB Expires / 8 2007
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION: NEW M/H (MODEL 6335) t 3 ► `Cr P•02-.3 eruct (kill/07
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: SKYLINE SETBACK:
VALUATION YEAR: 2006
SIZE: 43X41 BANK HEIGHT:
LABOR & INDUSTRIES APPROVAL?
SEWAGE DISPOSAL: ALT
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Total: 2
Routttii q Date:
`� IJLO
Type Amount Paid By: Date: Receipt: \PP4G \JEED
Manufactured Homes $163.00 LYK 09/28/06 84950 JUN 2007
Add. Manufactured Home $34.00 LYK 09/28/06 84950
Potable Water Application $55.00 LYK 09/28/06 84950 Q�s, rrittfttp atlmRlQn
Total: $252.00
• •
CERTIFICATE OF OCCUPANCY
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451 (800) 831-2678
PERMIT #: BLD06-00552
SITE ADDRESS: 111 MADRONA VISTA PL Issue Date: 06/25/2007
PORT LUDLOW, 98365 Final Date: 1/20/2009
APPLICANT: RUTH A WILLIAMSON PHONE: 360-779-6882
3009 NE BABOCK ST
POULSBO WA 98370-9307
SUBDIVISION: MADRONA VISTA 1ST AD Block: Lot: 5
PARCEL NUMBER: 970300004 Section: 34 Township: 28 N Range: 01 E
PROJECT DESCRIPTION: NEW M/H (MODEL 6327) SER# 2191-0325 WBWA
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2003 EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes (o
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 1/20/2009
I:\F_BLD_Occupancy.rpt 10/29/19
•
MANUFACTURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00552 Received Date: 9/28/2006
SITE ADDRESS: 111 MADRONA VISTA PL Issue Date: 6/25/2007
PORT LUDLOW, 98365
APPLICANT: RUTH A WILLIAMSON
3009 NE BABOCK ST
POULSBO WA 98370
SUBDIVISION: MADRONA VISTA 1ST AD Block: Lot:
PARCEL#: 970300004 Section: 34 Township: 28 N Range: 01 E
CONTRACTOR/ GOLDEN HOMES OF POULSBO PHONE: 360-697-3456
DEALER 19647 VIKING AVE NW
POULSBO WA 98370
360-697-4606
Contractor's License GOLDEHP950KB Expires 5/18/2009
PROJECT DESCRIPTION: NEW M/H (MODEL 6327)
MAKE: SKYLINE
YEAR: 2006
SIZE: 46X27
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 6/25/2008.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): `Z.'- o(-'O85
Stormwater FINAL Approval:
Blocking/Plumbing:
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps: 11"-lF2c_r-Th 1-2D- ; -
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT-LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY- SEE REVERSE
• •
SPECIAL CONDITIONS CASE # BLD06-00552
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on October 16, 2006 for the potential presence of Environmentally
Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC).
After an initial Geographic Information Systems mapping review and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property: Type
3 stream to the east of the parcel; SARPA& SUSC aquifer recharge area; at risk SIPZ.
2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson County.
3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
4.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within Susceptible
Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
5.) A Type 3 Stream (Fish and Wildlife Habitat Area) has been identified to the west of the
parcel. The stream will require a setback of 100-feet. The setback shall be measured
horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas
shall also have Buffers and Building Setbacks established.
6.) Stream buffers are areas that shall be maintained in their natural condition, however,
minor pruning or alteration of vegetation may be permitted as long as the function and
character of the buffer are not diminished.
7.) Among the native conifer species which may be used in buffers or for re-vegetation
include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow (Saliz Lasiandra), and Scouler's Willow (Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry (Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray (Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant (Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sam bucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium).
8.) Marine shorelines and islands are susceptible to a condition that is knownk seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
9.) The parcel is located within an At Risk SIPZ (seawater intrusion protection zone)
according to the County GIS map. There are voluntary and mandatory measures
identified in the Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective
September 23, 2002) that apply to well drilling proposals and building permit applications
on existing lots of record.
An At Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses between 100 mg/L and 200 mg/L (milligrams per liter).
10.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water
quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs) and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
11.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
12.) The identified Fish and Wildlife Habitat Area (Type 3 Stream), shall maintain a vegetative
buffer setback of 100-feet. The setback shall be measured horizontally from the Ordinary
High Water Mark (OHWM) to the proposed manufactured home.
13.) An additional setback of five (5) feet is required from the edge of the stream buffer area to
the proposed manufactured home.
14.) A permanent physical separation along the boundary of the stream buffer area shall be
installed and permanently maintained. Such separation can include installing logs, trees,
a hedgerow, or any other prominent physical marking approved by the UDC Administrator.
15.) Stream buffer perimeters shall be marked with temporary signs at an interval of one per
parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to
and during construction activities. The signs shall contain the following statement: "Buffer
- Do Not Remove or Alter Existing Vegetation."
16.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
17.) The applicant is proposing to create or add 2045 square feet of impervious surface and
4445 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington to control stormwater, erosion and sediment during construction. BMPs shall
address permanent measures to stabilize soil exposed during construction, and in the
design and operation of stormwater and drainage control systems.
18.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements#1 through#12 of the Department of Ecology's Stormwater Management
Manual for Western Washington to control stormwater, erosion and sediment during
construction. BMPs shall address permanent measures to stabilize soil exposed during
construction, and in the design and operation of stormwater and drainage control systems.
19.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
20.) Jefferson County determineat this proposal is categorically exempt fro i review under
the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(1)(b)(i).
21.) The revised site plan dated June 11, 2007 has been reviewed for consistency under the
UDC, and has been approved by Jefferson County Department of Community
Development. Any modifications, changes, and/or additions to the stamped, approved
site plan dated June 11, 2007 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
22.) This approval is for a manufactured home installation only. Any future permits on this site
are subject to review for consistency with applicable codes and ordinances and does not
preclude review and conditions which may be placed on future permits.
23.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
24.) Not more than 2 unlicensed vehicles shall be stored on any lot unless totally screened
from view of neighboring dwellings and rights-of-way. Such screening shall meet all
applicable performance and development standards specific to the district in which the
storage is kept, and shall be in keeping with the character of the area. Screening shall
meet the requirements of Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor
vehicles is prohibited except in those districts where specified as an autormobile wrecking
yard or junk (or salvage) yard and allowed as a permitted use in Table 3-1 or Chapter
18.18 JCC, and such storage shall meet the requriements of JCC 18.20.100, Automobile
wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor
vehicles be stored in a critical area.
25.) Minimum setback from Madrona Vista Place right-of-way shall be 20 feet. Minimum side
(north and south) yard setbacks shall be 5 feet. Minimum setback from the Type 3 stream
shall be 100 feet plus a 5 foot building setback from the stream buffer for a total of 105
feet.
26.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
27.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
28.) The building height is not to exceed 35 feet.
29.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
30.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
31.) The lot has been designated as RR 1:5 under the Jefferson County Comprehensive Land
Use Map effective August 28, 1998.
32.) An address of 111 Madrona Vista Place, Port Ludlow has been assigned to the lot.
Madrona Vista Place is a county local access road (C504209).
33.) The lot was created through the Madrona Vista 1st Addition Subdivision on October 7,
1963 under AFN 177207.
34.) A septic permit(SEP05-00263) was withdrawn on November 27, 2006. A septic permit
(SEP06-0283) was issued on November 27, 2006. A road approach permit
(RAP06-0201)will be issued with the building permit.
35.) The parcel is served by PUD#1 water system known as Bywater Bay(ID#02043).
36.) PRIOR TO OCCUPANCY OR BUILDING FINAL INSPECTION--FINAL APPROVAL OF
SEPTIC SEP06-283 IS REQUIRED.
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.JACK WVESTERMAN 0 Jefferson Gar Courthouse
ASSESSOR PO Ilox 1220. Port Townsend, W:11. 98368
(360) 385-910 i
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: U wI L1 CCfn'S 6/1
ADDRESS: I I i MaCtRailA Vl S' I PIA uz. P4 - lARA-L(tit) a �)alp S'
PHONE NO. 3(,Q0- -11 q r U` 2
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1)MOBILE ROME DATA:
(A) MAKE J‘"< ` " `v (B) MODEL A (C) YEAR lli
(D) LENGTH :1 -:(E) WIDTII (F)SERIAL # •M P.i )
(G) YOUR PURCHASE PRICE (Do not include sales taxi 61 1 Y7 PURCHASE DATE 12/(17
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTrrION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE ED id en h me of- Pouf srho
ADDRESS
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year.
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes CP
(B)IF LOCATED IN MOBILE HOME PARK:
NAME & ADDRESS OF PARK Lot/Space#
(C) IF NOT LOCATED IN MOBIV��E�A�tK� ^�S�
NAME OF LAND OWNER: �r(• W ''��ii �n 1
LOCATION ADDRESS I \1 U LS\-a � w Uc �r • ad 1 U w
REAL PROPERTY PARCEL #/DESCRIPTION 010 r W OO4
IR EC'FA\V ED
Signature of applicant
THANK YOU FOR YOUR HELP! St 2)ry' 2f
�
C�ss� Q
JO COSSELL, Property Technician OHO s110NO NO
• •
4� N �G� JEFFERSON COUNTY
' DEPARTMENT OF COMMUNITY DEVELOPMENT
'"' `4 621 Sheridan Street• Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
�`S�iINd�
Master Permit Application MLA: O( ` 3
.Q- 5
Project Description(incl a separate shgets as necessary):
Go I V -t-- a. v,u.-c-rult. --t--Lvv-c__--
Tax Parcel G Property /
Number: / Z ` Size: ,300 / I '3O(c g (acres/square feet)
Site Address and/or Directions to Projerty: (, Q,d4 Orta.. V/, fa. PI �` - (A) g83tf"
Property Owner(s)of Record: Ktti-FIN t f t t(,tom$m �+
Telephone: C3Co0) 77`r -6,8$a. Fax: email: ((ktWt1114,61,,co4YY1kf1'.06al
Mailing Address: 305ct Nb k" c 'Oeoc-K S4- 'P0..,,,15 ton W 4 .3'a 7 O
Applicant/Agent(if different from owner):
Telephone: a email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑Building ❑Variance(Minor,Major or Reasonable Economic Use)
d Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
d Single Family °Discretionary"D"or Unnamed Use Classification
Q Garage Attached/Detached ❑Special Use(Essential Public Facilities)*"
" Manufactured Home UBoundary Line Adjustment
d Modular OShort Plat**
0 Commercial* C IBinding Site Plan**
Q Change of Use ❑Long Plat**
❑Address i Road Approach [Planned Rural Residential Development(PRRD)/Amendments**
R Propane ❑Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions**
❑Stormwater Management ❑Shoreline Management Substantial Development**
❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Variance
❑Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
OWireless Telecommunication* °Jefferson County Shoreline Master Program Amendment
❑Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local state or federal permits required for this proposal, if known:
S DESIGNATION OF AGENT
I hereby designate t C "'car- 0 tel to act as my agent in matters relating
to/ /
thisis application for permit(s).
OWNER SIGNATURE Date: 7M1 p b
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or ifs knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and a •ed later•! spectio s. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of th appli do that haler gwaa s prior notice.
Signature: r� \\'IV/yy�� AAlt 4zr(*A —1•--.., Date: ii'/,
/O 42
The action or action Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even" u are in mpli ce with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf /abblle rgsp� ibili f adhering to and complying with the ESA. The Applicant has read this disclai r and igns and dates it below.
Signature: 1N�� _.• Date: 61 16 7 o ro
D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc
• S
BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming th bility of the General Contractor for the proposed project.
Signature: Date: cj/to/Y
f / GENERAL
Goaex vnes No Tl1REo HOjNfho ALLER: PHONE: 7! 11 Sip FAX:
V PP VU1 1111�✓J rn ,/�� 620 li�1 3 �U(,P�"1-�CQUCP
' MAILING ADDRESS: i 0(jt4� yi k'1 ` j. r►'ems ft AM) EMAIL:
1 CONTRACTOR'S LICENSE Cif 7O WAINS
M
NUMBER: (j f—"
t j\i P61 c�K-6 NUMBER 2 t+ 1
ARCHITECT/ENGINEER: 1 .<�v�j/ 1 112-- PHONE ( S)�Wu- FAX:( caje .L
MAILING ADDRESS: S a vv L_ EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
'ZI New 0 Wood Existing: -e- 0 Sewer
❑ Addition 0 Steel Proposed: 2- Bank 0 Community System
❑ Alteration/Remodel ❑ Concrete Total: L Height: Individual System
❑ Repair 0 Masonry SEP Permit# C*—2 3 '-
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: f Setback: ❑ Private well 0 Two Party
Type of Heat: , Proposed: i74Public
.,i.e ct yi c- Total: 3 Name of System:13'11W4- ( 4
0
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
0 Underground Tank 0 Above ground Tank Size of Propane Tank:
0 Heat Stove 0 Cook Stove 0 Woodstove ❑Fireplace Insert 0 Hot Water Tank 0 Pellet Stove O. Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review: 61,25
2n0 Floor Heated Consistency Review: 1,513 )
Other Heated Base fee: 1 ` _
Mezzanine Additional Section: 34 ;
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee: —I�j(l
V Y
Garage/Carport SUBTOTAL
50t)c"
Decks 911/Il6Approach fee vU
EXIST". AiS I2."—'
Other TOTAL: $ (1,5 / eiD
Receipt Number: '49
Cash/Check Number: 3CJ2r7
ESTIMATED COST(REQUIRED) Date: M
.Fair market value of all labor and materials foundation to finish
Initials:
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